<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:extend>
    <div class="span9">
        <h1 class="pageTitle">
            Complicaties <span class="divider">&gt;</span> <span class="subpage">Complicatie
				toevoegen</span>
        </h1>
    </div>
    <div class="row-fluid">
        <div class="span9">
            <fieldset class="form-horizontal">
                <form wicket:id="form">
                    <div class="control-group">
                        <label class="control-label">Datum complicatie <i class="icon-asterisk icon-purple"></i></label>
                        <div class="controls">
                            <div class="input-append">
                                <input wicket:id="datum" type="text" placeholder="dd-mm-jaar" size="16" class="input-small three-months">
                                <a href="javascript:void(0);" class="btn" onclick="$(this).prev().datepicker('show');return false;" title="Datum"><i class="icon-calendar"></i></a>
                            </div>
                        </div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Soort <i class="icon-asterisk icon-purple"></i></label>
                        <div class="controls" wicket:id="soort"></div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Ernst <i class="icon-asterisk icon-purple"></i></label>
                        <div class="controls" wicket:id="ernst"></div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Moment</label>
                        <div class="controls" wicket:id="moment"></div>
                    </div>
                    <div class="control-group">
                        <label class="control-label">Uitgevoerde coloscopie</label>
                        <div class="controls">
                            <select wicket:id="mdlverslag">
                                <option></option>
                            </select>
                        </div>
                    </div>
                    <div class="buttons">
                        <button class="btn btn-danger pull-left" wicket:id="inactief">Verwijderen</button>
                        <button class="btn" wicket:id="annuleren">Annuleren</button>
                        <button class="btn btn-primary" wicket:id="opslaan">Opslaan</button>
                    </div>
                </form>
            </fieldset>
        </div>
        <div class="span3">
            <div class="passport">
                <wicket:container wicket:id="passpoort"></wicket:container>
            </div>
        </div>
    </div>
</wicket:extend>
</html>
